Contractor Safety Guide
TME.B.Pol.17.2.1

Contractor Safety Guide

TME.B. Pol.17.2.1
Version: 2.0

Table of contents
I.

Introduction ................................................................................................................... 4

II.

Dictionary ....................................................................................................................... 4III.

Contractor’s obligations before the start of works .................................................... 6

1. Admitting a Contractor to perform works on the premises of Transfer Multisort Elektronik
Sp. z o.o. .............................................................................................................................................................................62.

Additional obligations of the Contractor ...................................................................................................7

IV.

Fundamental rules of occupational health and safety ............................................... 8

1.

General rules applicable on the TME Premises.......................................................................................82.

Rules of reporting accidents ...........................................................................................................................93.

Rules applicable in TME warehouses ....................................................................................................... 10

4.

Rules of work applicable in Technical Yards ........................................................................................ 11

5.

Rules of works at heights .............................................................................................................................. 11

6.

Rules of work involving power devices................................................................................................... 13

7.

Rules related to earthworks/digs .............................................................................................................. 14

8.

Rules of using cranes, lifts, and mobile cranes ..................................................................................... 16

V.

Rules of fire protection ............................................................................................... 16

VI.

Rules related to environmental protection................................................................ 17VII. Rules of property protection ...................................................................................... 18
VIII. Appendices ................................................................................................................... 19
Appendix no.1 Contractor’s Commitment ....................................................................................................... 20
Appendix no. 2 Short instruction concerning the course of procedure for the Contractor ........ 21
Appendix no. 3 List of particularly hazardous works ................................................................................. 23
Appendix no. 4 Representation on refraining from hazardous works ................................................ 25
Appendix no. 5 Permit for particularly hazardous works – construction, demolition, renovation,
and assembly works with a facility or its part in operation ..................................................................... 26
Appendix no. 6 Permit for particularly hazardous works – works in tanks, canals, insidetechnical devices, and in other dangerous closed spaces .......................................................................... 28
Appendix no. 7 Permit for particularly hazardous works – works involving hazardous materials............................................................................................................................................................................................ 31

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Appendix no. 8 Permit for particularly hazardous works – works at heights .................................. 34
Appendix no. 9 Permit for works involving fire hazard, works with open fire/welding/cutting,soldering, heating etc................................................................................................................................................ 36
Appendix no. 10 Permit for works involving power devices ................................................................... 38
Appendix no. 11 Permit for the Contractor to start works on the premises of Transfer Multisort
Elektronik Sp. z o.o. ................................................................................................................................................... 41
Appendix no. 12 Preparatory activities for works involving fire hazard ........................................... 42
Appendix no. 13 Example of an Instruction concerning safe performance of works (IBWR). .. 43
Appendix no. 14 List of Contractor’s Team members with a representation ................................... 49

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I. Introduction
When starting work on the premises of Transfer Multisort Elektronik Sp. z o.o., contractors should firstread the Occupational Health and Safety, Fire Protection, Environmental Protection, and Property
Protection rules described in this document.
Transfer Multisort Elektronik Sp. z o.o. strictly enforces ALL internal occupational health and safety
rules. A copy of those rules in the form of the Contractor Safety Guide and the related documents will be
provided to you by a TME Contractor Supervisor. You will be asked to undertake in writing to observe thoserules.
To avoid any doubt, it is hereby clarified that it is the Contractor’s obligation to fulfil all obligations which
are not explicitly assigned in the Contractor Safety Guide to an entity other than the Contractor.

II. Dictionary
TME/Company – Transfer Multisort Elektronik Sp. z o.o. with the registered office in Łódź, 41, Ustronna
Street;Ordering Party – Transfer Multisort Elektronik Sp. z o.o;Contractor – an external contractor chosen by TME to perform ordered works;
Team – employees, subcontractors, and all other parties whom the Contractor uses to perform the works
ordered on the TME premises; if the Contractor performs the works in person, the Contractor is also amember of the Team;
Contractor Supervisor – a person representing a department being a part of the TME structure which
substantially matches the scope of the works ordered from the Contractor; if there is no such departmentin the TME structure, then a person representing the department which has reported the need for the works
ordered from the Contractor;
DBPiK Department – Fire Safety and Coordination Department at TME;
Particularly Hazardous Works – works where the risk of accident is higher than in works of other type
due to their specific character, hazardous materials used, or local conditions of performance. The list ofPage 4 of 49

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particularly hazardous works requiring TME’s supervision is presented in Appendix no. 3 to this Contractor
Safety Guide;
Personal Protective Equipment (PPE) – all equipment worn or kept for protection against a single risk ora larger number of risks related to the presence of hazardous or harmful factors in the work environment,
including all accessories intended for that purpose;
TME Premises – TME real properties located in Łódź at 41, Ustronna Street and 1, Rozalii Street, in
Gospodarz, Rzgów municipality, at 4, Nasienna Street and all other real properties and their parts which areused by TME based on a legal title;
Technical Yards – yards on the TME Premises;
Power Device – power grids and systems, gas lines and systems, compressed air lines and systems.

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III. Contractor’s obligations before the start of works
1. Admitting a Contractor to perform works on the premises of Transfer Multisort
Elektronik Sp. z o.o.
The Contractor may be admitted to perform works on the premises of Transfer Multisort Elektronik
Sp. z o.o. only if the following requirements are met:
1.1 The Contractor undertakes to ensure that both the Contractor and the Team will get acquainted with
the Contractor Safety Guide, accept it for use, and observe the rules described in the Guide. A signed
Commitment of the Contractor (Appendix no. 1 to the Contractor Safety Guide) must be sent to theContractor Supervisor by e-mail in the form of a scanned image not later than 3 working days before
the start of the works, and the original signed Commitment should be provided to the Contractor
Supervisor no later than immediately before the start of the works.
1.2 The Contractor may not start the works until it has obtained a consent to perform works on the
TME premises, granted in line with the specimen being Appendix no. 11 to the Contractor Safety
Guide, and permits for separate categories of works issued in line with specimens being
Appendices no. 5-10 to the Contractor Safety Guide.
1.3 Before starting the works, the Contractor is obliged to present documents confirming the training,
medical certificates, and authorisations referred to in Appendix no. 14 to the Contractor Safety Guide
for inspection by the Contractor Supervisor.
1.4 Not later than 3 working days before starting the works, the Contractor is also obliged to provide
the following to the Contractor Supervisor:➢ information concerning the type of planned works, scheduled time of performance, and types ofhazards which may occur in relation to the works performed;➢ list of equipment to be used during the works, e.g. lifts, electric tools etc.;➢ information concerning the Team: the Contractor should submit to the TME Contractor Supervisor
a scanned image of a signed Representation stating that all members of the Team have appropriate
and valid medical certificates, up-to-date training in occupational health and safety, and allnecessary authorisations to perform particularly hazardous works (Appendix no. 14 to theContractor Safety Guide). The original signed Representation should be provided to the Contractor
Supervisor not later than immediately before the start of the works.

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1.5 If the Contractor is not going to perform particularly hazardous works, it fills in an appropriate
representation (Appendix no. 4 to the Contractor Safety Guide) which should then be provided to theContractor Supervisor immediately before the start of the works at the latest.

2. Additional obligations of the Contractor
To start works on the premises of Transfer Multisort Elektronik Sp. z o.o., the Contractor is obliged toobserve the following guidelines and fulfil the following obligations:
2.1 provide members of the Team with working clothes and protective equipment adequate to the works
performed;
2.2 the Contractor consents to have the Team supervised during the performance of the works on the TME
premises by the Contractor Supervisor, the TME Security Employee, or another person delegated by
TME. The supervision does not mean taking responsibility for the quality of the works or for ensuringsafety to the extent it is a responsibility of the Contractor;
2.3 when delegating the Team to perform the works, the Contractor is obliged to appoint the WorkManager who will manage the works of the Team, be responsible for preparing the site of the works
and workstations for individual members of the Team, admitting members of the Team to perform theworks, providing members of the Team with PPE, and for contacts with the Contractor Supervisor;
2.4 before starting the works, the Contractor is obliged to agree the rules of using the utilities necessary
to perform the works with the Contractor Supervisor; using the utilities without any agreement with
the Contractor Supervisor is prohibited;
2.5 the Contractor may commission its subcontractors to perform the works; in such a case the Contractor
takes full responsibility for the subcontractors’ works performed on the TME premises;
2.6 whenever the Contractor Safety Guide provides for an obligation to complete training or receive
briefing, the fulfilment of that obligation is confirmed with a participation in training/briefing,participant’s signature on the attendance register, the signature of the teacher/instructor on theattendance register (in the case of a remote training/briefing, only the signature of theteacher/instructor), and a positive mark received in an exam checking the knowledge obtained during
the training/briefing, as long as the teacher/instructor finds that such an exam is necessary;
2.7 the Contractor is obliged to provide the Team with details of TME employees trained in first aid
immediately after receiving such information from the Fire Safety and Coordination Department, tothe extent it was provided by that Department.

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IV. Fundamental rules of occupational health and safety
The rules listed below are complementary to the occupational health and safety regulations provided for in
the Polish Labour Code and are strictly binding on the whole TME Premises as internal safety rules forContractors. The Contractor is obliged to ensure that all members of the Team understand and always
observe the requirements described in this document.

1. General rules applicable on the TME Premises
1.1 The performance of works ordered by TME under the influence of alcohol or other intoxicants or
stimulants as well as possessing or taking alcohol, intoxicants, or stimulants on the TME Premises isstrictly prohibited.
1.2 Prohibited acts which, when committed, result in criminal liability, in particular participation in a fightor thefts, are not tolerated on the TME Premises. All such acts will be reported to competentauthorities.
1.3 Running is prohibited on the TME Premises.
1.4 It is prohibited to block, with any materials, free access to:▪ fire safety devices (hydrants, extinguishers, alarm buttons);▪ emergency exits;▪ electric steering cabinets;▪ fire gates (they must close during a fire).
1.5 It is prohibited to use malfunctioning or damaged tools.
1.6 It is prohibited to use electric tools in the conditions of increased humidity. Before starting
regulation/adjustment, cleaning etc., you should remember to disconnect the tool from power.
1.7 For one’s own safety, order and tidiness should be maintained by:➢ keeping one’s workstation orderly and clean for the whole period of the works (all spilled
substances and screws etc. scattered on the floor or on the ground must be cleaned and picked up
immediately, as they create the hazard of slipping or an environmental hazard);➢ all traffic routes, for pedestrians as well as for lifts/trucks, should be kept passable and unblocked(if the character of the works requires blocking the routes, you should first contact the TMEContractor Supervisor and obtain their consent);➢ storing materials carefully (nails or other sharp elements sticking out of packaging areunacceptable; waste material should be stored in dedicated containers (see the Rules related toenvironmental protection));

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Version: 2.0➢ the Contractor fencing off and marking the site of the works (the Contractor has the right andobligation to refuse to work if TME has failed to provide the Contractor with access to the work siteor if TME has provided the site in the condition which makes the start of the works impossible (e.g.
as a result of contamination));➢ storing wooden pallets only in stable horizontal piles; you must never stand on the pallets and use
them instead of platforms, ladders, or substitute fencing;➢ leaving the work places in proper order at the end of each day and after completing the work.
1.8 You should avoid laying long segments of power cables (extension cables) on the floor, in particularacross traffic routes. If it is absolutely necessary, you should secure the cables to avoid any possible
damage and mark the area e.g. by placing a warning sign.
1.9 Using gas cylinders:➢ cylinders with compressed gas must be stored vertically and must be secured at all times withvalves covered with caps when they are not in use;
➢ cylinders with flammable gas must be stored at a distance from canisters with strong oxidizers (e.g.
oxygen);➢ empty canisters must be clearly marked and separated from full canisters;➢ you may not leave gas canisters on the TME Premises for the night.
1.10. During the performance of the works where noise is emitted to the environment, the Contractor is
obliged to proceed according to legal regulations.
1.11. If it is found during the performance of the works by the Contractor that the permitted noise levels
have been exceeded, the person responsible for supervising the performance of the service on thepart of the Contractor is obliged to stop the works and take appropriate corrective actions agreed
upon with the Contractor Supervisor.
1.12. The Contractor is obliged to equip the Team with a first aid kit; in the case of using a first aid kit being
the property of TME, it is obliged to report the fact to the Contractor Supervisor.

2. Rules of reporting accidents
2.1 In the case of an accident or injury of the Contractor or a member of the Team, the Contractor
Supervisor should be notified of the fact immediately after the incident using the means ofcommunication which would be the fastest in the situation; you should confirm the information inwriting within 48 hours following the incident at the latest.

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2.2 The Contractor Supervisor shall immediately provide the information on the incidents referred to in
Sec. 2.1. to the Fire Safety and Coordination Department.
2.3 The Contractor Supervisor should be promptly notified of all events resulting in the destruction of or
risk to property, events being a breach of safety rules, or other non-typical events which are not asource of damage or risk for people or property.

3. Rules applicable in TME warehouses
3.1 You may move around a warehouse only in hard toe shoes.
3.2 You may only move along the marked routes. If there is no dedicated route, you should move according
to the instructions of the Contractor Supervisor.
3.3 It is strictly prohibited to enter zones fenced off with red and white tape.
3.4 In storage areas and workshops, in the direct surroundings of machines in operation, where contact ispossible with rotating elements, it is prohibited to wear loose hanging clothes and jewellery– necklaces, ties, etc.; long hair must be tied above the neck line.
3.5 You must keep a safe distance from all non-covered machine parts in operation. In TME warehouses,
it is prohibited to keep your hands and other body parts or clothes near the so-called “locking places”,
to avoid being caught by a machine.
3.6 It is strictly prohibited to reach beyond the safety covers of a machine in operation for any purpose.
3.7 Employees working with electrical devices, including distribution cabinets and technology steeringcabinets, must hold valid group 1 qualification certificates. Employees supervising the works must
hold a group 1 qualification certificates for the position of SUPERVISION.
3.8 Access to electric devices, including distribution cabinets (except for technology cabinets) is provided
based on a written permit issued by the Energetics Department.

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3.9 You should keep your workplace clean and tidy by:➢ keeping traffic routes for pedestrians as well as lifts/trucks passable and unblocked;➢ refraining from moving out of your workplace beyond the marked/fenced off area of the works;➢ leaving the workplace in proper order at the end of each day and after the completion of the works.
3.10 You should keep at least 3-metres’ distance from operating forklifts (for your own safety ALWAYS
maintain eye contact with the operator of the approaching forklift; before coming closer, always makesure that the operator can see you). In TME, a forklift always has the right of way.
3.11 You should use the required Personal Protective Equipment.
3.12 You should observe the procedures related to containing the spread of diseases applicable on the TME
Premises and presented during the occupational health and safety training delivered by the Fire Safety
and Coordination Department.

4. Rules of work applicable in Technical Yards
4.1 You should move around Technical Yards only in hard toe shoes and a fluorescent vest.
4.2 You should move only along the dedicated routes. If there are no such routes, you should moveaccording to the instructions of the Contractor Supervisor.
4.3 You should observe the principle of limited trust with regard to vehicles moving around TechnicalYards.
4.4 The area of the works should be fenced off with a red and white tape and a sign saying e.g. Work area,
no unauthorised access.

5. Rules of works at heights
5.1 It is required that workers use Personal Protective Equipment (helmet, hard toe shoes, fluorescentvest, protective gloves, equipment for works at heights) adapted to the type of works performed.
5.2 You may only use certified equipment (ladders, working platforms).
5.3 You have to put up a fence and mark works at heights in a visible way so as to prevent access of theoutsiders to the work site.
5.4 On the TME premises, it is prohibited to walk through or stay in places above which works at heights
are being performed. It is prohibited to walk and work below hanging loads, pallets placed on shelves,
or loads on a forklift. In areas where works are performed at heights and when working on selfpropelled mobile platforms, you must always use protective helmets. On the TME Premises, only
protective helmets with certificates may be used.

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5.5 The high storage warehouse (high-bay warehouse) is a particularly hazardous zone. That is why
only authorised parties have access to that zone. An external company may enter the high storage
warehouse only in the presence of authorised representatives of TME.
5.6 Rules of work on roofs
5.6.1 Works on roofs are particularly hazardous.
5.6.2 Works on roofs should be organized in the manner minimizing the risk of a possible fall, not basing
on systems stopping the fall of an individual or an object.
5.6.3 All works on roofs must be performed under the direct supervision of the Contractor’s representative
authorised to perform works at heights exceeding 3 metres, who will be present at the work site at
all times.
5.6.4 The Contractor’s representative supervising works on roofs should:➢ determine the anchoring points before starting works, according to the Instruction concerning
safe performance of works (Instrukcja Bezpiecznego Wykonywania Robót – IBWR) drawn up fora specific scope of works;➢ notify the Team members each time about the location of works on roofs;➢ is obliged to inspect the anchoring points before starting the work. Such an inspection is
confirmed by admitting workers to work on the roof.
5.6.5 Before starting the work, Team members should receive a briefing from the Contractor’s
representative supervising works on roofs concerning at least the following issues:➢ division of tasks between specific individuals;➢ order of performed tasks;➢ occupational health and safety requirements for separate activities.
5.6.6 Based on the existing collective protection systems, Team members should receive a detailed briefing
concerning the rules of selecting anchoring points, the manner of using a selected anchoring point,
and the allowed maximum number of people who may use an anchoring point at the same time. The
briefing is provided by the Contractor’s representative supervising works on roofs.
5.6.7 During the briefing, Team members should be instructed with regard to issues concerning themanner of performing works, in particular:➢ the way of going up and down the roof;➢ the way of transporting and receiving materials on the roof;➢ the type of security measures used to protect one against a fall (collective protection measures,
Personal Protective Equipment) based on the received information on individual protection
systems used in separate TME locations.

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5.6.8 You should ensure that the start of the works does not expose individuals present at the workstationand near the workstation to any hazard.
5.6.9 You should also prevent unauthorised access to places with the risk of falling objects or materials.
5.6.10 The works must be performed only in the weather conditions which do not pose a hazard for healthand life of individuals (i.e. wind speed below 10 m/s; works should not be performed after dusk,
during fog, rain, snowfall, black ice etc.).
5.6.11 The Contractor’s representative supervising works on roofs is responsible for providing individual
equipment protecting against a fall, for instructing workers how to use it, and for enforcing the useof such equipment.
5.7 Works at heights may only be performed with a support of another person.
5.8 Before starting works at heights, you should fill in the information on the works performed inAppendix no. 8 Permit for particularly hazardous works – Works at heights. The document should bedelivered to the Fire Safety and Coordination Department via the Contractor’s Supervisor. A
representative of the DBPiK Department will make a decision concerning the permit for starting works
at heights based on the collected and verified information.

6. Rules of work involving power devices
6.1 Works involving power devices must be performed according to the Regulation of the Minister ofEnergy of 28 August 2019 on occupational health and safety for work involving power devices.
6.2 The Contractor is obliged to provide the Team members with Personal Protective Equipment adequate
to the type of works performed.
6.3 The Personal Protective Equipment referred to in Sec. 6.2 must be operational and have valid technicalcertificates (if required).
6.4 Team members must hold valid group qualification certificates within the scope adequate to the typeof works performed, referred to in the Regulation specified in Sec. 6.1.
6.5 In particular, Team members performing works involving electric devices, including distribution
cabinets and technology steering cabinets, must hold valid group 1 qualification certificates. A personsupervising the works must hold a group 1 qualification certificate for the position of SUPERVISION.
6.6 The qualification certificates referred to in Sec. 6.4 and 6.5 must be available for inspection at all times
for the Contractor Supervisor or another individual supervising the works on behalf of TME.
6.7 The Contractor is not authorised to perform any moving or switching operations involving powersystems and devices without the TME’s consent, except for situations where human life or TME
property are being saved.

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6.8 For an unauthorised switch-off of power devices, the Contractor will be charged with costs equal tothe value of damage suffered by TME as a result of the switch-off.
6.9 Works involving power systems and devices can only be started after the Contractor obtains a written
permit for power works issued by the TME Energetics Department (Appendix no. 10 Permit for works
involving power devices).
6.10 The permit contains information on Team members, the date and place of the works, and the scope of
the works to be performed.
6.11 Having analysed the presented information concerning the works to be performed, the TME Energetics
Department presents the conditions for the works, i.e. guidelines (if any), in the written permit (in thepart containing supplementary information), which are absolutely binding for the Contractor.
6.12 The issued permit is a written confirmation that TME has been informed about the operations and thescope of the works to be performed by the Contractor.
6.13 The issued permit is not a formal admission referred to in §2(8) and §2(10) of the Regulation
mentioned in Sec. 6.1.
6.14 After each change of the date of the works, the scope of the works, or Team members specified in thepermit, it is necessary to obtain a new permit.
6.15 At TME, it is a standard procedure that all works are performed in potential-free conditions.
6.16 It is allowed to perform works with power on in exceptional situations, subject to TME’s consent, butsuch works are performed at the risk and responsibility of the Contractor.
6.17 Electric works should be performed in a safe manner according to Art. 25 of the Regulation of the
Minister of Energy of 28 August 2019 on occupational health and safety for work involving powerdevices.
6.18 TME makes it possible to perform the following works without switching off the power: replacementof fuses and sources of light (e.g. lightbulbs, fluorescent lamps) with non-damaged casing and settingin circuits with voltage below 1 kV, measurements and tests according to the company’s manuals, otherworks only after having applied special measures ensuring safety at work and provided for in manuals.
6.19 Access to electric devices, including distribution cabinets (except for technology cabinets) is provided
based on a written permit issued by the TME Energetics Department.

7. Rules related to earthworks/digs

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7.1 Before starting work, all individuals present at the construction site must be acquainted with theInstruction concerning safe performance of works (IBWR) and the applicable safety and healthprotection plan (Plan Bezpieczeństwa i Ochrony Zdrowia – BiOZ) (if it is obligatory to draw it up).
7.2 The IBWR documents and the BiOZ plan (if required according to construction law) must be submitted
by the Contractor to the TME Contractor Supervisor for reading. A specimen Instruction concerning
safe performance of works is Appendix no. 13 to this Guide.
7.3 You should use required Personal Protective Equipment specified in the Instruction concerning safe
performance of works and the BIOZ plan (if it is required).
7.4 Earthworks must be performed according to the design which specifies the location of undergroundsystems and devices which may be present within the area of the works to be performed. That
documentation should also contain information on the manner of securing the digs and the results ofgeological tests.
7.5 If there are power, gas, telecommunication, heating, water, or sewage systems in the surrounding of
the works to be performed, the earthworks should be performed within a safe distance determined by
the site manager together with the system owners or administrator.
7.6 During the earthworks, you should:➢ fence off places near underground systems and mark them with warning signs (it is not sufficient
to mark them with tape);➢ perform the earthworks near those installations manually, make the searching digs manually;➢ during digging in places accessible to individuals who are not involved in the works, place barriers
with red warning lights for dusk and the night. The barriers should be placed 1 m from the edge ofthe dig and 1.1 m above the ground;➢ if the site of the earthworks may not be fenced, the contractor should ensure permanent
supervision over the site.
7.7 When performing earthworks using mechanic equipment, you should map out the dangerous zone andmark it properly.
7.8 It is prohibited for any person to stay between a wall of the dig and the digger, even when the digger
is not working at the time.
7.9 Digs with non-reinforced vertical walls, with no strutting or support, may be made only down to thedepth of 1 m in dense soil, when the strip of the area around the dig of the width equal to the depth ofthe dig is not under load.
7.10 Non-reinforced digs deeper than 1 m but less than 2 m may be made if the results of soil tests andgeological-engineering documentation allow. In other cases, it is necessary to secure the dig (e.g. withprefabricated supports).

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7.11 Works in digs and excavations that are deeper than 2 m and earthworks performed using the opencast
method must be performed by at least two people.
7.12 Before starting works in a dig, you should each time check the condition of the support or the
escarpment.

8. Rules of using cranes, lifts, and mobile cranes
8.1 Only individuals holding valid UDT certificates and medical certificates may use lifts, cranes and mobile
lifts.
8.2 The devices referred to above should be in a good working order (with a valid UDT inspection
certificate).
8.3 Before starting works, you should determine their scope, considering the parameters of moved loads
and places of lifting and lowering.
8.4 You should section the area of the operation of the device and fence off the dangerous zone using
warning tapes or barriers.
8.5 Before starting works, cranes and mobile cranes should be levelled and their supports should besecured against digging into the ground.
8.6 You should observe the allowed load levels.
8.7 The work site should be properly lit. If the operator’s field of vision is smaller than the work area, you
should ensure the assistance of a signaller.
8.8 You may not perform works during wind exceeding allowed thresholds specified for the device
concerned.

V. Rules of fire protection
1.

It is prohibited to use open fire on the TME Premises. You may smoke on the premises only in dedicatedplaces. Smoking in other places constitutes the grounds for terminating the contract with theContractor.

2.

Performing works involving fire hazard, such as:- welding;- gas and electric cutting;- gas (flame) welding and soldering;- heating systems, devices, valves;- heating glue, pitch, tar etc.;

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Version: 2.0- using fireworks and explosive materials etc.;- using substances, gas, and dust which may form explosive mixtures;is allowed only with available mobile extinguishing devices, which must be located in the direct
surroundings of the works (you should keep a safe radius of app. 10 m of area free from any flammablematerials, if possible). If the requirement concerning the 10 m of area free from any flammablematerials is not met, works involving fire hazard may be performed after those places are additionallysecured with extinguishing blankets.
3.

It is the obligation of the Contractor to prepare places for performing the works involving fire hazard.
The actions which should be completed by the Contractor are specified in Appendix no. 12 Preparatory
actions for works involving fire hazard.

4.

Such works may be performed after having obtained the Permit for works involving fire hazard, works
with open fire/welding/cutting, soldering, heating etc. (the specimen permit is presented in Appendix
no. 9 to this Guide).

5.

It is obligatory to use Personal Protective Equipment during works involving fire hazard (masks,
goggles, protective clothing).

6.

It is possible to perform works at heights near the sprinkler system and smoke sensors only after
consultation with the Fire Safety and Coordination Department.

7.

Welding devices and other devices emitting high temperature should be turned off and secured after
you have stopped to use them.

8.

The site of performing hazardous works should be fenced off with warning tape and secured against
unauthorised access.

VI. Rules related to environmental protection
1.

When staying on the TME Premises, you should observe all rules of waste sorting which are applicable
at TME.

2.

3.

On the TME Premises, general waste should be sorted into the following fractions:▪

paper;▪

plastic, metal;▪

glass;▪

BIO;▪

mixed waste.

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devices, cleaning, maintenance, and repairs unless the service contract states otherwise. Therefore,
unless the contract states otherwise, the Contractor is obliged to dispose of the waste produced as aresult of the works performed.
4.

If TME is the producer of waste, the Contractor is obliged to place the resulting waste in suitablecontainers according to the information received from the Contractor Supervisor.

5.

If minor quantities of waste are produced, it is allowed to place them in waste bins located in thewarehouse/technical yard (according to labels on the bins).

6.

It is prohibited to pour out any chemicals, oils, or any other fluids into the sewage system or in any
other place on the TME Premises.

7.

The Occupational Health and Safety and Environmental Protection Specialist as well as theRepresentative for the Integrated Quality Management and Environmental Management System havethe right to audit the places where services are provided by Contractors and issue recommendations
concerning environmental protection.

8.

All operations performed by the Contractor which pose or may pose a risk for the environment on the
TME Premises need to be agreed upon with the Contractor Supervisor.

VII. Rules of property protection
1.

Before crossing the gates leading to the warehouse, you should report all objects you bring in to thesecurity staff.

2.

On the TME Premises, random checks are performed of people leaving the warehouse. A selectedindividual is strictly obliged to submit themselves to the check.

3.

Each case of suspected theft will be promptly reported to competent authorities.

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VIII. Appendices
Appendix no. 1 Contractor’s Commitment;
Appendix no. 2 Short instructions for the Contractor;
Appendix no. 3 List of particularly hazardous works;
Appendix no. 4 Representation on refraining from particularly hazardous works;
Appendix no. 5 Permit for particularly hazardous works. Construction, demolition, repair, and assembly
works with no breaks in the operation of the facility or a part thereof;
Appendix no. 6 Permit for particularly hazardous works. Works in tanks, canals, inside technical devices,
and in other dangerous closed spaces;
Appendix no. 7 Permit for particularly hazardous works. Works involving hazardous materials;
Appendix no. 8 Permit for particularly hazardous works. Works at heights;
Appendix no. 9 Permit for works involving fire hazard, works with open fire/welding/cutting, soldering,heating etc.;
Appendix no. 10 Permit for works involving power devices;
Appendix no. 11 Consent for the contractor to start works on the premises of Transfer Multisort Elektronik
Sp. z o.o.;Appendix no. 12 Preparatory actions for works involving fire hazard;
Appendix no. 13 Specimen Instruction concerning safe performance of works (IBWR);
Appendix no. 14 List of members of the Contractor’s Team with a representation.

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Appendix no.1 Contractor’s Commitment
I hereby undertake to train Team members within the meaning of the Contractor Safety Guide with regard
to regulations concerning Occupational Health and Safety, Fire Protection, Environmental Protection, andProperty Protection included in the Contractor Safety Guide.

1.

I ensure that Team members strictly observe the regulations included in the Contractor Safety
Guide during the works performed on the premises of Transfer Multisort Elektronik Sp. z o.o.

2.

I confirm that Team members have been instructed concerning the rules of reporting accidents
described in the Contractor Safety Guide.

3.

I consent to Team members being submitted to checks upon leaving the premises of Transfer
Multisort Elektronik Sp. z o.o.

4.

I acknowledge and accept that in the event of theft or damage to property committed by a Team
member and suffered by TME I will be obliged to redress the resulting damage.

5.

I acknowledge that a repeated failure to observe the rules described in the Contractor Safety Guide
gives Transfer Multisort Elektronik Sp. z o.o. the right to expel Team members breaching therules from the TME Premises or to stop the works immediately and terminate the contract forreasons on the part of the Contractor.

........................................................
......................................................................................................
COMPANY NAME/SEAL

NAME, POSITION……….……………………………………………………
Date and signature

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Appendix no. 2 Short instruction concerning the course of procedure for theContractor

Contractor ….…………………

Contractor Supervisor (representing TME): …….………………
Tel. no.:Course of procedure:
1.

Agree with the Contractor Supervisor what information should be sent before starting the works and
when.

2.

Send appropriate information to the Contractor Supervisor.

3.

Agree the detailed starting date for the works with your TME Supervisor.

4.

Confirm the detailed planned date and time for starting the works to the Contractor Supervisor at least
2 working days before.

5.

On the day of starting the works, notify the Contractor Supervisor by phone of your arrival.

6.

The Contractor Supervisor representing TME will obtain a permit for entering the relevant TME
location and will indicate parking spaces for your cars.

7.

The Contractor Supervisor will provide entry cards/id badges and parking cards.

8.

Before the start of the works, an employee from the DBPiK Department will provide a training, verify
your preparation to perform particularly hazardous works, and issue an appropriate permit forparticularly hazardous works of a given type.

9.

After the successful verification of all information and the completion of appropriate preparation to
perform the ordered works, a permit will be provided for the Contractor to start works on the premisesof Transfer Multisort Elektronik Sp. z o.o.

10. After that, the Contractor Supervisor or other delegated TME employee will show you the place for
performing the works. In that place, it will be possible to start the works according to the adopted
schedule and all arrangements.
11. Perform the works with due care, observing, in particular, the rules concerning occupational healthand safety and fire protection as well as other regulations included in the Contractor Safety Guide.

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12. In the event of any failures, possibly hazardous situations, or situations being a hazard tohuman life or health, notify a TME Security Employee immediately and proceed according to
the received instructions.
13. If an evacuation is necessary, proceed according to the TME evacuation procedure applicable to a given
location.
14. Having completed the works, tidy up the site of the works. Collect your tools, equipment, and otherthings.
15. Leave the work site in a condition which does not expose others to any hazards.
16. Report the completion of the works to the TME Contractor Supervisor and agree with them all details
concerning the acceptance procedure of the completed works.
17. When leaving TME, return your id badge and parking card to the TME Contractor Supervisor or amember of security staff of the facility in question.

Contact data:
Security:
Security Łódź – Rozalii 1 (office building): tel. 607 770 951; email: ochrona_rozalii@tme.pl
Security Łódź – Ustronna 41 (CLŁ): tel. 607 038 911; +48 42 612 01 00; email: ochrona_ustronna@tme.pl
Security Gospodarz – Nasienna 4 (CLR): tel. 507 845 736; email: ochrona_greenfiled@tme.pl

Fire Safety and Coordination Department:
bezpieczenstwopozarowe@tme.pl

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Appendix no. 3 List of particularly hazardous works

1. Construction, demolition, repair, and assembly works performed with the facility or its
part in operation in the places where workers are present and performing other works orwhere machines or other technical devices are in operation, works in digs and excavations
deeper than 2 m, and works with the use of heavy construction equipment, such as diggers
etc.
2. Works in tanks, canals, wells, manholes, inside technical devices, and in other closed
spaces, where you can enter through hatches or holes of small sizes or where entry is
difficult for other reasons.
3. Works involving hazardous materials, i.e. chemical substances and mixtures recognized as
particularly hazardous based on the information resulting from the safety data sheets, inparticular classified as at least one of the categories listed below:• explosive substances and mixtures;• oxidizing substances and mixtures;• extremely flammable substances and mixtures;• highly flammable substances and mixtures;• flammable substances and mixtures;• very toxic substances and mixtures;• toxic substances and mixtures;• harmful substances and mixtures;• corrosive substances and mixtures;• irritating substances and mixtures;• allergizing substances and mixtures;• carcinogenic substances and mixtures;• mutagenic substances and mixtures;• substances and mixtures with harmful effects on the ability to reproduce;• substances and mixtures hazardous for natural environment.
4. Power works
To perform works of that type, it is necessary to obtain a written permit for electric works.
The document should be issued by the Energetics Department – Technical Division.

5. Works at heights:

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•
•
•
•

Works above 1 m;
Works in elevated places not intended for people;
Works on scaffoldings;
Works on roofs, poles, masts, tower constructions, chimneys, constructions with noceiling.

6. Works involving fire hazard:• Cutting;• Welding;• Grinding etc.

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Appendix no. 4 Representation on refraining from hazardous works…………………………………….

…………………………………….
(date, city)…………………………………….
(Company name/stamp)

REPRESENTATION

I represent that ……………………………………………………….. (company name) will not perform particularly
hazardous works specified in the List of particularly hazardous works.

On behalf of the Contractor………………..…………………………………….
(name, position, and signature)

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Appendix no. 5 Permit for particularly hazardous works – construction,
demolition, renovation, and assembly works with a facility or its part in operation

Stamp of the Contractor
to which this Permit pertains

Łódź, (date) .................................

Permit no. .........
for particularly hazardous works –construction, demolition, renovation, and assembly works with afacility or its part in operation
SECTION A. To be filled in by the Contractor Supervisor
1.

Contractor’s name and names of individuals performing particularly hazardous works:
a)
b)
c)

2.

Name of the Contractor’s Supervisor:

3. Type of works performed: ...................................................................................................................................................

4. Place of work ..............................................................................................................................................................................

SECTION B. To be filled in by the Contractor

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5. Scope of works to be performed in the order of works and with names of responsible individuals for each
item:
a)
b)
c)
6. Work performance time: from ............................................... to .......................................................
7. Types of hazards which may occur in relation to the works:a)b)c)……………………………………………………
Name and signature of the Contractor’s representative

SECTION C. To be filled in by an employee of TME DBPiK Department
8. Organization of works:

yes

no

a) Notification of employeesb) Fencing off the work zonec) Marking the zone
I consent to the start of the works listed in p. 3……………………………………………………………………………………………..
Name and signature of an employee from the Fire Safety and
Coordination Department

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Appendix no. 6 Permit for particularly hazardous works – works in tanks,
canals, inside technical devices, and in other dangerous closed spaces

Stamp of the Contractor
to which this Permit pertains

Łódź, (date)..................................

Permit no. .........
for particularly hazardous works –works in tanks, canals, inside technical devices, and in otherdangerous closed spaces
SECTION A. To be filled in by the Contractor’s Supervisor
1.

Contractor’s name and names of individuals performing particularly hazardous works:
a)
b)
c)

2.

Name of the supporting person:

3.

Name of the Contractor’s Supervisor:

4.

Type of works to be performed ..................................................................................................................

5.

Place of work ...............................................................................................................................................

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SECTION B. To be filled in by the Contractor
6. Scope of works to be performed in the order of works and list of works with names of responsible

individuals:a)b)c)
7. Work performance time: from ............................................ to ....................................................

8. Types of hazards which may occur in relation with the works to be performed:
a)
b)
c)

8. Organization of works
yesnoa) Emptying the tankb) Support of another personc) Is the tank hatch open?

On behalf of the Contractor………………..…………………………………….
(name, position, and signature)

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SECTION C. To be filled in by an TME DBPiK employee
9. Security measures used (after a prior inspection of their technical condition):yesnoa) helmetb) work at heights kit (safety cord, safety
harness, self-braking device, shock absorber)c)

protective hard toe
shoes
I consent to the start of the works listed in p. 4………………………………………………………………………………………………..
Name and signature of an employee from the Fire Security and
Coordination Department

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Appendix no. 7 Permit for particularly hazardous works – works involving
hazardous materials

Stamp of the Contractor
to which this Permit pertains

Łódź, (date)..................................

Permit no. .........
for particularly hazardous works –works involving hazardous materials
SECTION A. To be filled in by the Contractor Supervisor
1. Contractor’s name and names of individuals performing particularly hazardous works:
a)
b)
c)

2. Name of the supporting person:
3. Name of the Contractor Supervisor:
4.

Type of works to be performed ..................................................................................................................

5.

Place of work ........................................................................................................................................

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SECTION B. To be filled in by the Contractor
6. Scope of works to be performed in the order of works and list of works with names of responsible
individuals:
a)
b)
c)

7. Work performance time: from .......................................... to .....................................................

8. Types of hazards which may occur in relation to the works to be performed:
a)
b)
c)

On behalf of the Contractor………………..…………………………………….
(name, position, and signature)

SECTION C. To be filled in by a TME DBPiK employee

9. Organization of works:yesa) Knowledge of the professional risk
assessment

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Version: 2.0b) MSDS sheets available
10. Safety measures used (after a prior inspection of their technical condition):

yes

no

a) Protective glovesb) Protective gogglesc) Protective mask

I consent to the start of the works listed in p. 4…………..…………………………………………………………………………………..
Name and signature of an employee of the Fire Security and
Coordination Department

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Appendix no. 8 Permit for particularly hazardous works – works at heights

Stamp of the Contractor
to which this Permit pertains

Łódź, (date) .................................

Permit no. .........
for particularly hazardous works – works at heights

SECTION A. To be filled in by the Contractor Supervisor
1.

Contractor’s name and names of individuals performing particularly hazardous works:
a)
b)
c)

2.

Name of the supporting person:

3.

Name of the Contractor Supervisor:

4.

Type of works to be performed .................................................................................................................................................

5

Place of work .............................................................................................................................................................................

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SECTION B. To be filled by the Contractor
6. Scope of works to be performed in the order of works and list of works with names of responsible
individuals:a)b)
7. Work performance time: from .......................................... to ..............................................................
8. Types of hazards which may occur in relation to the works to be performed:a)b)

On behalf of the Contractor………………..…………………………………….
(name, position, and signature)

SECTION C. To be filled in by a TME DBPiK employee
9. Safety measures applied (after a prior inspection of their technical condition):yesnoa) helmetb) works at height kit (safety cord, safety harness, self-braking
device, shock absorber)c) protective hard toe shoes
I consent to the start of the works listed in Sec. 4…………………………………………………………………………………..
Name and signatureof an employee of the Fire Safety and Coordination Department

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Appendix no. 9 Permit for works involving fire hazard, works with open
fire/welding/cutting, soldering, heating etc.

Stamp of the Contractor

Łódź, (date) ..................................

to which this Permit pertains

Permit no. .........
for works involving fire hazard, works with open
fire/welding/cutting, soldering, heating etc.
1. Contractor’s name and names of individuals performing particularly hazardous works:a)b)c)
2. Name of the Contractor Supervisor:

4. Place of work ........................................................................................................................................................................................
/facility, systems, devices, department etc./

5. Type of work ………...........................................................................................................................................................................
6. Time

of

work

from

(day,

hour)

.................................................................

until

(day,

hour)

....................................................................
7. Fire/explosion hazard in the place of work ..........................................................................................................
/specify what it results from/

8. Manner of performing the work...................................................................................................................................................
9. Individuals responsible for:a) preparation of the place of work ………………………………………………………………………….…………………………..
/name and signature/b) preparation of safety measures and securing the performance of works involving fire hazard:..............................................................................................................................................................................
/name and signature/c) use of safety measures, organization of works, instructions:……………………………………………
/name and signature /d) turning off power .........................................................................................................................................................
/name and signature/

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10. I consent to the start of works involving fire hazard.
.......................................................................................................
/name and signatureof an employee of the Fire Safety and Coordination Department/

11. The work was completed on ............................................ at ...........................................
12. The place of work and its surroundings were checked; no negligence which may result in fire was found......................................................................................................................................................................................................
/name and signature of the person performing the works /13. I confirm that the works have been accepted ....................................................................................................................
/name and signature of the TME Contractor Supervisor/

14. The place of work was checked in terms of fire safety .....................................................................................................
/name and signature of an employee of the Fire Safety and Coordination Department/

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Appendix no. 10 Permit for works involving power devices

Permit for works involving power devices

ORDER:
Concerning:

Permit no.:Permit issue date:
Contractor Supervisor:
Contractor name:QUERIS ID:

CONTRACTOR TEAM MANAGER:
Name

Position

Qualification no.

Valid until

Position

Qualification no.

Valid until

CONTRACTOR TEAM:
Name

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TIME SCHEDULE
Starting date:Completion date:
Working hours:

PLACE OF WORKS:
Location/area/place:

SCOPE OF WORKS:
Describe the scope of works to be
performed:(described by the Contractor)

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ADDITIONAL INFORMATION
Provide additional information forthe permit:

INSTRUCTIONS
1.

2.

3.

According to the Regulation of Transfer Multisort Elektronik Sp. z o.o. no. 1/2018/BHP
concerning the determination of the list of types of works performed by at least two
individuals, the Contractor is hereby instructed that all electric works listed in this permit should
always be performed by at least two individuals.
Before starting the works, according to the occupational health and safety recommendations
resulting from the Regulation of the Minister of Energy of 28 August 2019 on occupational
health and safety for work involving power devices (Dziennik Ustaw [the Polish Journal of Laws]
2019, item 1830), the team of the Contractor’s employees must wear and have personal protective
equipment appropriate for the type of works to be performed.
The Contractor team is not authorised to perform, on their own, any moving/switching operations
on devices or systems which are the property of TME.

Contractor’s representative, date and signature
Contractor Supervisor, date and signature
Person issuing the permit, date and signature

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Appendix no. 11 Permit for the Contractor to start works on the premises ofTransfer Multisort Elektronik Sp. z o.o.

Stamp of the Contractor
to which this permit pertains

Łódź, (date) ………………………………..

CONSENT FOR THE CONTRACTOR TO START WORKS ON THE PREMISES OF
TRANSFER MULTISORT ELEKTRONIK SP. Z O.O.

Having analysed the received information, the Fire Safety and Coordination Department hereby grants
its

consent

for[company]…………………………………………………..

…………………………………………………………………………….

on

to

start

the

[date(s)]…………………………………..

works
on

the

premises of Transfer Multisort Elektronik Sp. z o.o.

…………………………………………………………………………………..
name and signatureof an employee of the Fire Safety and Coordination Department

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Appendix no. 12 Preparatory activities for works involving fire hazard

Preparation of the place of works involving fire hazard
Before starting works involving fire hazard, you should:➢

remove all flammable materials from the buildings, rooms, or places where works involving fire
hazard are to take place;➢

move flammable objects or non-flammable objects in flammable packaging to a safe distance fromthe place where works are to be performed;➢

if the condition referred to above may not be met, all devices and flammable materials should besecured against fire, welding spatter etc. by covering them with extinguishing blankets, metal
sheets, asbestos boards, or in a different manner;➢

before starting the works, you should check in the adjacent rooms for any materials or objects
which may be set on fire as a result of thermal conduction, welding spatter etc.;➢

if there are through, installation, cable etc. openings near the place of works involving fire hazards,
they should be sealed with non-flammable materials to prevent the dispersion of welding spatter,cut-off metal parts etc. to adjacent rooms or lower floors; all cables and electric wires as well as gas
and other system lines with flammable insulation should be protected against spatter, direct fire,
and mechanical damage;➢prepare metal containers with water for cut-off metal parts, welding wire, and electrodes;➢

do not perform works involving fire hazard in rooms where painting works or other works
involving flammable substances were performed on the same day.

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Appendix no. 13 Example of an Instruction concerning safe performance of works(IBWR).

Data of the works
Type of works:
Name and addressof the place ofworks:
Contractor:

1. Planned time schedule of the works[Provide the planned dates of the task, including the schedule, technological breaks, and specify whether the works will
be performed during the day or at night]a) the works will be performed from .................... to ....................
b) planned breaks:- during a shift: from …… to …….
- in a week: e.g. on Saturdays, Sundays, and public holidays- during the performance of the works: ……………………
c) the works will be performed during the day/at night:- in a single shift: from. …… to ….
- in two shifts: 1st shift from …… to …….
2nd shift from .…… to ………
- night shift from …… to ….

2. Place of the works
detailed place where the works will be performed

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Version: 2.0…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………

3. Weather conditions requiring breaks in the works

FactorOperations affected by the factor

Threshold values for safe
performance of the works
above which operations
should not be performed

TemperatureWind
Rain/snow
Visibility
Storm
Other undesirable
weatherphenomena

4. Scope of the worksa) Sequence and manner of performing the works[List the main stages, starting from the delivery of materials to the place of works to the completion of the works;
describe how individual operations should be performed safely, considering the planned equipment, tools, and collective
and personal protective equipment. Pay special attention to particularly hazardous works and works involving highlevels of risk. To make the manner of performing the works clearer, add photos, drawings, and sketches.]

1.
2.
3.
b) Hazardous substances and preparations[Provide the names of hazardous substances to be used during the task. Enclose safety data sheets for hazardous
substances.]

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Version: 2.0c) Basic personal protective equipment

SymbolCategory/class

ComplianceProtective helmet with chinstrap

3- or 4-points’ chin strap

EN 397

Protective glasses, goggles, orvisor

at least 1F

EN 166

Working clothes, warningvest, or protective fluorescentclothing

at least class 2

EN ISO 20471

at least 2

EN 388at least S3

EN ISO 20345

Name

Protective gloves
Attention! It is prohibited to use
working/protective gloves when
operating a circular saw and moving
hands near rotating machine anddeviceelements(unlessthemanufacturer specified otherwise).

Shoes protecting ankles

Apart from the obligatory personal protective equipment, it is required to use the equipment
appropriate for occurring risks, according to the Task Risk Assessment.

d) Risk assessment for the tasks performed[Assess the risk related to the works to be performed after the application of risk mitigation measures. Consider therisks resulting from the use of hazardous substances and preparations. When identifying individual risks, rememberthat it is e.g. a fall from a height that is a risk rather than work at heights itself.]

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5

S5

S10

D15

D20

D25

4

M4

S8

D12

D16

D20

3

M3

S6

S9

D12

D15

2

M2

M4

S6

S8

S10

1

M1

M2

M3

M4

S5

1

2

3

4

5

Severity

Risk table

Probability

Severity:

Probability:
1 = Very improbable
2 = Improbable
3 = Probable
4 = Highly probable
5 = Almost certain

Low(Acceptable)

1 = Minor injuries
2 = Light injuries
3 = Severe injuries
4 = Heavy injuries
5 = Fatal injuries

After the assessment,
please markAverage(Requires constant
one of the squares *below
with “X”
monitoring)High(Unacceptable)

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5. Evacuation
The assembly point during evacuation as well as the evacuation route and manner must be
consistent with the applicable evacuation procedure for a given facility of Transfer Multisort
Elektronik Sp. z o.o.
5.1 Emergencies
Procedure in emergencies:[Specify the procedure in the situation involving risk for health or life, e.g. with an employee trapped in the excavation oran employee hanging on a safety harness]

6. Particularly hazardous works[Specify which particularly hazardous works will be performed during the tasks and identify the supervising person]

Types of works**Particularly hazardous works are performed based on an appropriate permit.

Supervisor

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7. List of equipment and tools necessary to perform the works[List the planned equipment and tools; specify the type of qualifications or whether a UDT certificate is required]Type of qualifications
required

Equipment name

UDT certificate
required (Y/N)

8. List of individuals performing the works who are acquainted with theInstruction and division of tasks[Provide names of workers as well as their positions, company name, assigned tasks, and qualification requirements.
After they have read the Instruction, enter the date and place the signature.]

Name

Position

Company

Assigned tasks

Qualification
requirements

Date andsignature

On behalf of the Contractor………………..…………………………………….
(name, position, and signature)

Contractor Safety Guide

TME.B. Pol.17.2.1.
Wersja: 2.0

Appendix no. 14 List of Contractor’s Team members with a representation…………………………………….

…………………………………….
(date and place)…………………………………….
(Contractor name/stamp)

No.

Name

Occupational
health andsafetytraining/validity
date/

Medicalcertificate/validity
date/Specialist medical
certificates, e.g.
- for work at heights- audiometric tests- alpinist tests/validity date/

Qualifications/type, class,number/First aid training/certificate date/

Knowledge ofoccupationalrisk /date ofreading theinformation/

1

2

3

4

5

On behalf of the Contractor………………..…………………………………….
(name, position, and signature)